Healthcare Provider Details

I. General information

NPI: 1578344644
Provider Name (Legal Business Name): MARTIN PEDRO MOYA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/13/2023
Last Update Date: 10/13/2023
Certification Date: 10/13/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 W 27TH ST
LUMBERTON NC
28358-3075
US

IV. Provider business mailing address

LOS ALAMOS 1111, LA RUFINA
LA CALERA CORDOBA
X5000
AR

V. Phone/Fax

Practice location:
  • Phone: 910-671-5000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080N0001X
TaxonomyNeonatal-Perinatal Medicine Physician
License Number2000-01220
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: